An emergency department nurse is establishing a plan of care for a client admitted with a history of tonic-clonic seizures and a current upper respiratory infection. Which safety measures should the nurse implement to prevent injury during a potential seizure event? Select all that apply.
- Ensure functioning wall suction and oxygen delivery equipment are immediately available at the bedside.Answer
- Pad the side rails and maintain the bed in the lowest possible locked position.Answer
- CSecure the client's arms and legs using soft limb restraints if forceful muscle contractions begin.
- DInstruct the unlicensed assistive personnel (UAP) to assess and document the client's neurological status post-seizure.
- Loosen any restrictive clothing around the client's neck or chest as soon as seizure activity is observed.Answer
- FKeep a padded tongue blade at the bedside to place in the client's mouth to prevent tongue biting.
Answer
The correct interventions to implement are ensuring suction and oxygen are available, padding the side rails and keeping the bed in the lowest locked position, and loosening restrictive clothing around the client's neck or chest.
The correct interventions prioritize maintaining a patent airway and protecting the client from environmental trauma. Padding the side rails and keeping the bed in the lowest locked position creates a safe perimeter that minimizes blunt force injury if the client experiences violent motor movements. Having suction and oxygen readily available is essential for rapidly clearing secretions to prevent aspiration and treating potential hypoxia. Loosening restrictive clothing around the neck further prevents airway compromise and allows for uninhibited chest expansion.
Step-by-Step Solution
Key Concept
Seizure Precautions and Injury Prevention